Laparoscopic Techniques: Vaginal Vault Suspension

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Dr. Paul Indman:  “This is Dr. Paul Indman from the National Congress of Gynecologic Endoscopy in Cancun, and I’m fortunate to have with me Dr. Terry Vancaille.  Terry, you were talking about vaginal vault suspension and laparoscopic techniques.  What I’d like to know and probably most of us gynecologists who are used to doing things vaginally, as we may do sacrospinous fixations and other procedures entirely vaginally, why do we need to add the laparoscope to the equation?”

Dr. Terry Vancaille:  “That’s indeed a very good question.  I personally believe that the mode of access whether one performs a surgery transvaginally or transabdominally is not necessarily the main question but the aim of the surgery should be to reconstruct the anatomy to its normalcy.  That may actually require a combination of both the vaginal and the abdominal access but even if we look at the literature, there are very few comparative studies between the laparoscopic approach or the abdominal approach whether it is laparoscopic or open and the transvaginal approach.  These studies, however, point towards the abdominal approach as being certainly superior and having a lower recurrence rate.  Historically, physicians or gynecologists have been reluctant to do open surgery because it was more traumatic for the patient so we have emphasized the vaginal approach in order to be less invasive and have patients who are recuperating faster.  The laparoscopy now allows us to do the same abdominal procedures but, again, with less trauma and, therefore, hopefully obtain better long term results in terms of vaginal vault prolapse.”

Dr. Paul Indman:  “Terry, I think most of us who do sacrospinous fixations have been fairly happy with the actual vault suspension.  On the other hand, it seems that we have problems with the anterior compartment; often there’s a lateral defect that comes back to haunt us a year or two later.  Those are the failures that I see most of the time, they’re anterior failures.  Is this what you’re addressing primarily during your surgery, and if so, how do you do that?”

Dr. Terry Vancaille:  “Unfortunately, high anterior failures are everybody’s nightmare.  When we look at the normal anatomy, the weakest point of the vaginal conduit is at the top of the fascia posteriorly and at the top of the pubocervical fascia anteriorly.  So it actually is the vault both anteriorly and posteriorly that represents the weakest point in the vaginal support structures, especially after hysterectomy that will accentuate the anterior weakness of the upper vaginal conduit.  Now reinforcing that parenteral wall is very difficult because the boney end ligamentary structures, which support the pelvis, are farthest away, obviously, from the upper portion of the vagina.  The methods developed for a cure of high anterior wall defects from a vaginal point of view are basically all resulting in an amputation of that part of the vagina, whereas if we approached the upper anterior vaginal wall abdominally and reinforce the support structures, for instance, by inserting a non-absorbable mesh, then connect to some structures such as the lateral pelvis or the peritoneum, I believe then we will obtain more long lasting results.”

Dr. Paul Indman:  “Terry, you talk about using mesh, as gynecologists, I think most of us are very concerned about using mesh since we don’t use it routinely.  How often do you see infections or other problems using synthetic mesh in your surgery?”

Dr. Terry Vancaille:  “Overall, the rejection rate whether induced by infection or not is estimated to be around 5% or less and, unfortunately, there is very few information available in literature.  The people with the longest experience in this field are from Paris, France, the followers of Doctors who first described these procedures using foreign material sometime in the fifties and their published rate is 5% or there about.  The rejection of the mesh is indeed a very difficult problem to deal with, as one has to remove the foreign material through whichever route is the easiest to do it through.  Nevertheless, the use of what I call a prosthesis because that’s what the mesh is, it replaces the natural supportive structures and will become an integral part of the pelvic floor relaxation surgery.  That is a required and normal discussion whether the support structures are either worn or torn and the torn support structures are sutured where the tear is, whereas if the entire structure is worn out, it has to be replaced.  That’s where the prosthesis comes into place, especially in cases of vault prolapse with or without high anterior and posterior wall relaxation of the insertion of a prosthesis that will be important, and that is in patients especially where there has not been a clear injury to the pelvic floor structures, namely, they have not had a traumatic delivery.  The materials of the future will probably not be the current nylon but rather either the cadaver tissue that’s now being relatively widely used in the United States but not elsewhere in the world and materials that are derived from silicone which has proven to be the best material in terms of tolerance by the human body.”

Dr. Paul Indman:  “Terry, all of this is impressive surgery and seems fairly complicated.  Do you think that there is still a role for vaginal hysterectomy and vault suspension or do you think that that procedure is totally obsolete now?”

Dr. Terry Vancaille:  “The short answer is no.  The vaginal surgery is a wonderful surgery and it’s a true purview of the gynecologist.  I’ll continue to perform vaginal surgery, hopefully, for many, many years to come.  The gynecologist who has a keen interest in pubic floor relaxation should be familiar with vaginal surgery as well as abdominal surgery for the treatment of these conditions.  Again, the key is to attempt reconstruction to near normal anatomy.”

Dr. Paul Indman:  “Great, all of that is very enlightening, and I certainly hope to hear more about that.  That’s Terry Vancaille in Cancun, thank you.”